VICTIMS OF TORTURE VICTIMS OF TORTUREAssoc.
Professor Dr. Azhar M. Zain
Psychotherapy Clinic
USM Hospital
Kubang Kerian
16150 Kota Bharu
Recently the MMA and the Rehabilitation and Research Centre for Torture Victims in Copenhagen held a well organized and highly informative seminar on victims of torture in Kuala Lumpur. I am very grateful to the MMA for selecting me as a seminar participant. It has enlightened me to the various forms of torture in the world and the effects it has had on the victims. It was also an opportunity to have an overview on the psychological treatment of torture. The book on Psychotherapy of Torture by the Research Centre is very comprehensive and indeed helpful. I would certainly recommend anyone interested to read it.
However as a practicing doctor, we may not get to see many torture victims as described by the presenters of the seminar but we do see child abuse, sexual abuse and rape and domestic violence. Occasionally I get to see surviving victims of severe motor vehicle accidents or assaults (following housebreaking, etc) with psychological sequelae. These are of course victims of a form of torture too. In psychological medicine terminology we generally consider them to be suffering from Post Traumatic Stress Disorder (PTSD). It is described as a disorder in which characteristic symptoms develop following exposure to an extreme traumatic/stressor involving direct personal experience of an event that involves actual threat or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to one’s physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. The person’s response to the event involve intense fear, helplessness, or horror(in children it is disorganized or agitated behaviour). The resulting characteristic symptoms include persistent reexperiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal. The full symptom picture lasts for more than a month and the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
A great deal of research has been done on these group of patients to identify the actual psychopathology so as to have an effective treatment regiment. Most of the areas of research have focused on the personality profiles, psychodynamic aspects, time factor of torture, chronicity of torture, support system, etc. All seem to be showing some importance but is unable to predict the prognosis of these victims. However, recently, a few studies have managed to throw some light on the possibility of predicting response of these victims and as such able to show which victims should be given more extensive therapy and the specific aspects of therapy component that they require. Not all victims develop psychological sequelae. Indeed, initial post traumatic reactions may reflect a normal response to the traumatic experience, from which the majority of victims go on to recover. In a longutidinal study of 64 female rape victims, Rothbaum et al (1992) found that 94% of the women met symptomatic criteria for PTSD one week after the assault; this fell to 65% four weeks later, and 47% continued to meet the criteria three months following assault. This means that although many victims recover after a relatively short period of time, a substantial proportion will suffer from persisting PTSD. The same pattern was also found for non-sexual assault by Riggs et al (1995). Current research involves identifying victims likely to have persisting PTSD.
In psychotherapy, the cognitive approach is making strides in this aspect. Cognitive models of PTSD suggest that individual differences in the appraisal of traumatic events and their sequelae may be particularly important in determining the persistence of the disorder. The cognitive factors considered potentially relevant include;
(1) Thoughts that occur during the traumatic event. Ehlers et al (1996) identified a bipolar construct, mental planning verses mental defeat, relating to thoughts during the assault. They found good outcome following imaginal exposure therapy was associated with mental planning during rape, and inferior outcome was associated with lack of mental planning during the rape.
(2) The victim’s subsequent appraisal of the way they behaved and felt during the assault may be important. Some indirect evidence that negative appraisals of actions are associated with poorer outcome comes from studies looking at internal attributions for negative outcomes and studies addressing self blame. In two studies of survivors of shipping disasters internal attributions for negative events involving the individual (assessed within 6 months of the disaster), were significantly correlated with depression and intrusions up to 19 months post disaster (Joseph et al, 1991, 1993). With respect to self blame Frazier and Schauben (1994) found that post-rape psychopathology was positively associated with blaming one’s actions, and with blaming aspects of one’s personality.
(3) The victim’s appraisals of the way in which other people responded to them in the aftermath. Several investigators have reported data suggesting that those who perceive that other people have failed to react in a positive or supportive manner, report greater post-traumatic psychopathology (Keane et al, 1985; Joseph et al, 1992; Riggs at al, 1991). Two studies have also indicated that negative social interaction following sexual assault were associated with poor adjustment (Davis et al, 1991; Ulman, 1995).
(4) The victim’s interpretation of the PTSD symptoms. Foa & Riggs (1993) postulated that appraisals of symptoms and signs of incompetence or inadequacy may act to intensify PTSD. Ehlers and Steil (1995) proposed, with respect to the maintainance of symptoms of intrusion, that the ‘negative idiosyncratic meaning of intrusions’ acts to increase distress and to make it more likely that the individual will engage in strategies to control the intrusions. These strategies may then act to maintain or even to exacerbate intrusive symptoms. Negative interpretations of symptoms also play a central, maintaining role in panic disorder (Clark, 1986; Ehlers et al, 1988) and it is of interest to to note that individuals with PTSD have Anxiety Sensitivity Index scores that approach those of panic patients (Taylor et al, 1992).
(5) The global negative beliefs that the individual may hold about themselves, their world, and their future following the assault. There has been considerable disscussion of the role of shattering (Janoff-Bulman & Frieze, 1983) and confirmation (Foa & Riggs, 1993) of pre-existing beliefs in the development of PTSD. The former refers to the proposal that a traumatic event presents the individual with information that is inconsistent with pre-existing beliefs. This is said to shatter core assumptions: such as ‘the world is benevolent’, ‘the world is meaningful’, and ‘the self is worthy’. In some cases, a traumatic event presents the individual with information that acts to confirm and reinforce pre-existing negative beliefs about the safety of the world and the worthiness of the self.
A pilot study reported recently by Dunmore et al (1997) indicated that the five cognitive factors mentioned above are associated with persistence of PTSD symptoms. However some of the factors may be a consequence rather than a cause of persistence. The results however has helped us to understand PTSD better and has made psychological treatment of the victims more focussed. The above issues must be taken into consideration when treating victims. For example victims with mental defeat during assault should not be treated with imaginal exposure as this could make them worst. Each case needs to be analysed in detail and a suitable treatment model planned based on the current evidence of research knowledge for each individual victim. Much more information are needed and a more extensive research to provide this information is underway but in the meantime, we have currently ample experimental and scientific knowledge to treat victims of torture or PTSD patients with more accuracy and hopefully with good results. This however can only happen if there is a strong support and effort by everyone concerned with the treatment of these victims as the management is a team approach although, the psychotherapy may be on an individual basis initially. I applaud the MMA for taking the initiative for this highly sensitive but sadly neglected group. An action plan needs to be instituted and implimented as soon as possible.
PERSIKOL can also help by considering a
group to aid abused children and/or women which are present in Kelantan
but have no real avenues to look for help. PERSIKOL should start the initiative
at least for battered women because the SCAN team has already been established
for children but none for women.